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Curing Electronic Health RecordSystems: Why EHR SafetyCommanded Fortune Magazine’sCoverRaj Ratwani, PhD (@RajRatwani)Zach Hettinger, MD, MS (@ZachHettinger)MedStar Health National Center for Human Factors in Healthcare (@MedicalHFE)Ruth Kochenderfer (ruth.s.Kochenderfer@marsh.com)Marsh JLT Specialty
Disclosures Research is funded by: Agency for Healthcare Research and QualityThe Pew Charitable TrustThe National Science FoundationThe National Library of Medicine Member of the 21st Century Cures Act Health InformationTechnology Advisory Committee Opinions expressed here are our own and not of the committee
EHR Related Closed Legal ClaimsNumber of Source: TDC
EHRSeeWhatWeMean.orgElectronic Health Record · Errors Happen Regularly · Everyone Has ResponsibilitiesBackground on EHRsUsability & Safety VideosCalls to Action
User Interface DesignContext IndependentFont SizesIconsColors & ContrastLayoutCognitive Task SupportContext DependentWorkflow DesignVisualizationMemory AidsError Anticipation
% of safety reports1.735m Patient SafetyEvent Reports30%25%20%15%10%5%0%1,956 (.11%) explicitly mentioned EHRvendor and reported patient harm557 (.03%) containedlanguage suggestingusability as an issueEHR Usability Issues Identified from Safety Event ReportsHowe, J., Adams, K., Hettinger, A. Z. & Ratwani, R.M. (2018). Electronic HealthRecord Usability Issues and Potential Contributions to Patient Harm. JAMA
EHR Usability and the Impact on Pediatric SafetyAnalyzed 9,000 likely EHR and medicationrelated safety reportsOver a third of analyzed reports weremedication errors associatedwith EHR usability issues100%% of Analyzed Safety ReportsReports sourced from 3 healthcaresystemsSite 1Site 2Site 390%80%84.5% of the EHRusabilitymedication issueswere over- orunder dose errors70%60%50%40%30%20%10%0%SystemFeedbackDisplay ofInformationDifficult DataEntryWorkflowSupportUsability Categories609 reached the patientRatwani, R. M., Savage, E., Will, A., Fong, A., Karavite, D., Muthu, N., . & Grundmeier, R. (2018). Identifyingelectronic health record usability and safety challenges in pediatric settings. Health affairs, 37(11), 1752-1759.
Wide Variability in EHR Usability and SafetyEHR FunctionsX-ray(left elbow, wrist,forearm)Prednisone Taper(60mg, reduce by 10mgevery 2 days for 12 days)Usability &Safety MetricsVendor ASite 1Vendor ASite 2Vendor BSite 3Vendor BSite 4Time (sec)64.124.333.355.5Clicks31.17.78.115.5Error Rate25%16.7%35.7%20%Time (sec)148.6152.7175.1178.7Clicks34.92042.328.2Error Rate16.7%41.7%50%40%Ratwani et al. (2018) A Usability and Safety Analysis of Electronic Health Records. Journal of the American Medical Informatics Association.
Recent Allegation with EHR Usability Bariatric patient for gallbladder surgery Physician decides to keep patient overnight Intends to order pulse oximetry continuous, instead order placed asone time for the next day Patient found unresponsive at 10:20am on the second day Permanent brain damage Usability flaws: Submenu read: pulse oximetry continuous, with further submenu stating once“Pulse oximetry: continuous once”Defaults to 10am the next day
What now? Federal Policy Changes Optimize EHR usability policies Eliminate “gag clauses” Create an EHR safety reporting system Ensure certification adherence Bolster safety initiatives
Why Health IT Safety r-CenteredDesignHazardReporting &AnalysisAdverse EventReportingClinical DataRiskAssessmentClaims AnalysisImplementation“Best Practices”User Analytics& Help mIntegrated Patient Safety Transformational(PST) Model
Surveillance Methodologies Reactive Harm Events Help Desk Tickets Patient Safety Event Reports Proactive EHR Flight Data RecorderONC Change PackageSAFER GuidesPEW Safety Use Cases
EHR Flight Data Recorder Record in Real-Time Cockpit Voice Instruments/Displays Avionics
“At 02:10:05 UTC the autopilot disengaged because the blockedpitot tubes were no longer providing valid airspeed information, andthe aircraft transitioned from normal law to alternate law 2. Theengines' auto-thrust systems disengaged three seconds later.Without the auto-pilot, the aircraft started to roll to the right due toturbulence, and the pilot reacted by deflecting his side-stick to theleft.”Palmer B. Understanding Air France 447. William Palmer; 2013 Jul 25. ISBN 9780989785723.
A Health IT BlackBoxRecreate “accidents” as they unfolded
Why is Health IT Surveillance Important?
Missing White Blood Cell Count
Wrong Route Errors
iles/playbook/pdf/usability-change-plan.pdf
Safer guides
mation-technology
Be ww.iihs.org28
r@marsh.com@MedicalHFE@RajRatwani@ZachHettinger
with EHR usability issues 609 reached the patient Reports sourced from 3 healthcare systems 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% System Feedback Display of Information Difficult Data Entry Workflow Support ports Usability Categories Site 1 Site 2 Site 3 84.5% of the EHR usability medication issues were over- or under dose errors Ratwani .
